As an intern doctor in Gyne department , this presentation outlines the steps of assessment of an infertile couple including history taking , examinations and relevant investigations and imagings .

1. Prepared by : Azah Mukhtar Affat
Gyne - Intern Misrata Infertility Center
22/1/2017

2. Objectives :
 Overview
 Definitions
 Chances of conception
 Etiology of infertility
 General guidance in evaluation of infertile
couple (history and clinical examination)
 Evaluation of male partner
 Evaluation of female partner

3. Overview:
 Infertility is a problem through out history ,
however increasing rate has been noticed.
 The first successful birth of a
“ test tube baby” Louise Brown in
1978 in Oldham Genera hospital UK.
• Robert G, Edward the physiologyst
Who developed the treatment was
Awarded the Nobel brize in Medicine in 2010.

4. Definitions:
 Infertility is the failure to conceive (regardless of cause)
after 1 year of unprotected intercourse .
 Primary infertility applies to those who have never
concieved , where as Secondary infertility designated
those who have concieved at some time in the past .
 Infertility affects approximately 10-15% of reproductive-
aged couples.
 Fertility is defined as the capacity to reproduce or the
state of being fertile.
 This term should be differentiated from Fecundability,
which is the probability of achieving a pregnancy each
month, and Fecundity, which is the ability to achieve a
live birth within 1 menstrual cycle.

5.  The fecundability rate in the general reproductive-
aged population is fairly constant and is
approximately 0.22 per month .
 The estimated fecundity rate is 0.15-0.18 per month,
representing a cumulative pregnancy rate of 90%
per year.
 Because fecundability rates are higher in younger
women and lower in older women, counseling a 40-
year-old woman to wait a year before seeking fertility
services is inappropriate .
 The prevelance of women diagnosed with infertility
app 13% with range 7-28% , depending on the age
of the women .
 Ethinicity or race appears to have a little effect on
prevelance.

6. Chances of conception:
 People who are concerned about their fertility should
be informed that over 80% of couples in the general
population will conceive within 1 year if:
 the woman is aged under 40 years and
 they do not use contraception and have regular
sexual intercourse.
Of those who do not conceive in the first year, about
half will do so in the second year (cumulative
pregnancy rate over 90%).

7. Etiology of inferility :
 Infertility is caused by male and/or female factors.
 Male and female factors each account for
approximately 35% of cases.
 Often, there is more than one factor, with male and
female factors combined causing 20% of infertility.
 In the remaining 10% of cases, the etiology is
unknown.
 Couples with unknown etiology can be categorized
as unexplained infertility or normal infertile couples
(NICs), indicating that all findings from standard tests
used in the infertility workup are normal.

8. ‫المبيعات‬,
ovulatory, 29%,
29%
‫المبيعات‬, tubal,
16%, 16%
‫المبيعات‬,
male only,
21%, 21%
‫المبيعات‬,
unknown,
18%, 18%
‫المبيعات‬,
endometriosis,
7%, 7%
‫المبيعات‬, uterine,
3%, 3%
‫المبيعات‬,
cervical,
2%, 2%
‫المبيعات‬,
multible,
4%, 4%
Causes of subfertility devided in male and female
factors
ovulatory
tubal
male only
unknown
endometriosis
uterine
cervical
multible

9.  In normal infertile couples NIC, the actual cause for
infertility cannot be detected;
 Perhaps there is dysfunctional interaction between
the sperm and the oocyte, poor quality of the embryo,
or a disruption at the implantation site.
 In the future, identifying a mutation or the absence of
a specific gene as the cause of infertility may be
possible in this patient population.

10. Female Factor Infertility
:
 Female factor infertility can be divided into several
categories :
Cervical
Uterine
Ovarian
Tubal
Other
 Although stress and distress (anxiety or
depression) have been considered factors in
reducing pregnancy chances with ART.

12. Cervical factors
:
 Cervical factor infertility can be caused by stenosis
or abnormalities of the mucus-sperm interaction;
 Cervical factors account for 5-10% of infertility.
 Cervical mucus production and characteristics
change according to the estrogen concentration
during the late follicular phase.
 Fertile cervical mucus (often descriptively referred to
as egg-white cervical mucus) is necessary for
transport of the sperm upward from the vagina into
the uterus and is produced in response to the
midcycle estrogen surge

13.  Mucus secretion may be altered by hormonal
changes and medications, especially drugs like
clomiphene citrate, which decrease the production.
Hypoestrogenism may cause thickened cervical
mucus, which impairs the passage of sperm.
 Cervical stenosis can cause infertility by blocking the
passage of sperm from the cervix to the intrauterine
cavity.
 Cervical stenosis can be congenital or acquired in
etiology, resulting from surgical procedures,
infections, hypoestrogenism, and radiation therapy.

14. Uterine factor infertility:
 uterine factors may be associated with primary
infertility or with pregnancy wastage and premature
delivery
 Uterine factors can be congenital or acquired.
 may affect the endometrium or myometrium and are
responsible for 2-5% of infertility cases.
I. Congenital defects :
 The full spectrum of congenital Mullerian
abnormalities varies from total absence of the
uterus and vagina (Rokitansky-Küster-Hauser
syndrome) to minor defects such as arcuate uterus
and vaginal septa (transverse or longitudinal)

15.  The most common uterine malformations observed
during the past 40 years were drug induced. From
the late 1950s until the early 1970s, diethylstilbestrol
(DES) was used to treat patients with a history of
recurrent abortion .
 Later in life, these so-called DES daughters are
found to have T-shaped uteri that result in infertility,
recurrent miscarriage, and preterm
deliveries. malfunction of the fallopian tubes,
menstrual irregularities, and the development of
clear cell carcinoma of the vagina.

17. II. Acquired defects :
 Endometritis associated with a traumatic delivery,
dilatation and curettage, intrauterine device, or any
instrumentation (eg, myomectomy, hystrescopy) of
the endometrial cavity may create intrauterine
adhesions or synechiae (ie, Asherman syndrome),
with partial or total obliteration of the endometrial
cavity.
 Intrauterine and submucosal fibroids are very
common.
 Placental polyps may develop from placental
remains.

18. Ovarian factor infertility:
 Ovulation is intricately regulated by HPO axis.
 Ovarian factor infertility accounts for 40% of cases of
female infertility.
Central factors :
1. Hyperprolactinemia ( drug, tumour,empty celia )
2. Hypothalamic insufficiency .
3. Pituitary insufficiency ( trauma , tumour, congenital)
4. Chronic hyperandrogenic anovulation.

19.  Peripheral factors :
1. Gonadal dysgenesis
2. Premature ovarian failure
3. Ovarian tumours
4. Ovarian resistant
 Metabolic disease :
1. Thyroid disease
2. Liver disease
3. Renal disease
4. Obesity
5. Androgen excess , adrenal or neoplasm

20. Tubal factors:
 Abnormalities or damage to the fallopian tube
interferes with fertility and is responsible for abnormal
implantation (eg, ectopic pregnancy).
 Obstruction of the distal end of the fallopian tubes
results in accumulation of the normally secreted tubal
fluid, creating distention of the tube with subsequent
damage of the epithelial cilia (hydrosalpinx).
 Factors can be congenital or aquired :
 Congenital absence of the fallopian tubes can be due
to spontaneous torsion in utero followed by necrosis
and reabsorption.
Elective tubal ligation and salpingectomy are Acquired
causes.

21. Peritoneal factors:
 Anatomical defects or physiologic dysfunctions of
the peritoneal cavity, including :
 Infection : PID , Appendicitis
 Peritoneal adhesions secondary to previous pelvic
surgery, endometriosis, and ovarian cyst rupture .
 Large myomas, pelvic masses, or blockage of the
cul-de-sac interferes with the accumulation of
peritoneal fluid and interferes with the normal oocyte
pickup mechanism.

22. Male Factor Infertility :
 Male factor infertility can be divided into pretesticular,
testicular, and posttesticular etiologies :
I. Pretesticular factors :
i. Hypothalamic dysfunction (Kallman Syndrome)
ii. Pituitary failure (tumour, radiation,surgery)
iii. Prolactinomas
iv. gonadotropin deficiencies
v. Cushing syndrome
vi. Adrenal hypreplasia
vii. Thyroid disorders

23. II. Testicular factors :
Testicular factors can be genetic or nongenetic in
nature ;
i. Genetic : Klinefelter syndrome is the most
common chromosomal cause of male infertility and
results in primary testicular failure.
ii. Nongenetic etiologies : include drugs, radiation or
chemical exposure ,cryptorchidism , mumps
orchitis , trauma, and varicoceles.

24. III. Posttesticular factors :
 Posttesticular factors are those that do not allow
the normal transport of sperm through the ductal
system.
 Can be congenital or aquired :
i. Congenital : exposure to DES in utero may have
ductal obstruction.
Congenital bilateral absence of the vas
deferens (CBAV) is seen in men with cystic
fibrosis.
ii. Aquired :infections, surgical procedures, and
trauma may cause ductal blockage.

25. Factors Affecting both sexes:
1. Environmental and Occupational factors :
- Concern regarding the impact of environmental
factors on fertility is increasing. Published semen
analysis reports from 1985 confirm a 20% decrease
of sperm concentration compared with reports
published in the 1960s.
- Excessive radiation damages the germinal cells.
- Exposure to lead, other heavy metals, and
pesticides has also been associated with male
infertility.
- excessive heat exposure, microwave radiation,
ultrasonography, and other health hazards are
controversial as infertility-inducing factors.

26. - Toxic effects related to tobacco, marijuana, and other
drugs .
- Smoking : reduces fertility in females and semen
quality in males .
- Alcohol : use by males interferes with the synthesis
of testosterone and has an impact on sperm
concentration.
- Exercise : compulsive exercise is deleterious,
especially for long-distance runners. Jogging
stimulates the secretion of endorphins; excessive
secretion of endorphins interferes with the normal

27. - Body weight : over or under weight can affect
ovulation , women with BMI > 29 or < 19 will have
difficulty conceiving .
- Drugs :
o NSAID : inhibit ovulation
o Chemotherapy : destroy rapidly deviding cella (e.g
gamets).
o Cimetidine , sulphasalazine, androgen injections
(affect sperm quality ).

28. General guidane on evaluation of an
infertile couple :
 Infertility is a problem that involves both partners. The
consultation is incomplete if only the woman is
evaluated.
 Diagnostic testing is unnecessary if the couple has
not attempted to conceive for at least 1 year, unless :
o the woman is 35 years old or older.
o they have a history of a male factor infertility.
o endometriosis, a tubal factor, DES exposure, pelvic
inflammatory disease, or pelvic surgery.
 Anxiety is very common.
• A brief explanation of the physiology of reproduction
and reassurance are usually enough to lessen the
anxiety of the couple.

29. How to assess :
 The initial clinical assessment should begin through
history of both partners .
I. Medical history for female factor infertility :
 in utero (DES) exposure .
 History of pubertal development .
 Present menstrual cycle characteristics (length,
duration, molimina)
 Cotraceptive history
 Prior pregnancies , outcomes.
 Previous surgeries , especially pelvic .
 Previous history of PID.

30.  Previous fertility treatment
 Use of lubricants , impotence , dysparenia.
 General health ( diet , weight stability , excercize
pattern )
 A history of weight changes, hirsutism, frontal
balding, and acne should ba addressed .
 A complete review of systems may be helpful to
identify any endocrinological or immunological
problem that may be associated with infertility.

31. II. Medical history of male factor infertility :
 Congenital abnormalities.
 Undescended testes.
 Perior paternity.
 Occupation (setting for prolonged time , excessive heat
exposure) .
 Exposure to toxins.
 History of testicular trauma , surgery to testes.
 Previous infections, mumps ,measles and treatment.
 Drugs and medications.
 General health (diet, exercize, review of systems).
 Ask about previous semen analysis results, history of
impotence, premature ejaculation, change in libido .

32. Clinical examination:
 The history should guide the physical examination beyond
the general evaluation .
 Note the following for female physical examination:
GENERAL EXAMINATION :
 Routine records of blood pressure, pulse rate, and
temperature (if applicable) are needed.
 Measure height and weight to calculate the body mass
index, and measure arm span when indicated.
 Perform an eye examination to establish the presence of
exophthalmos, which can be associated with
hyperthyroidism.

33.  epicanthus fold , lower implantation of the ears and
hairline, and webbed neck can be associated with
chromosomic abnormalities.
 Examine the skin to establish the presence of acne,
hypertrichosis, hirsutism and Acanthosis nigricans .
 Carefully evaluate the thyroid gland to exclude gland
enlargement or thyroid nodules.
 Breast examination to evaluate breast development
and to seek abnormal masses or secretions,
especially galactorrhea.

34. GYNECOLOGICAL EXAMINATION :
 Should include an evaluation of hair distribution,
clitoris size, Bartholin glands, labia majora and
minora, and any Condylomata accuminatum or other
lesions that could indicate the existence of venereal
disease.
 Inspection of the vaginal mucosa may indicate a
deficiency of estrogens or the presence of infection.
 evaluation of the cervix should include a
Papanicolaou test and cultures for gonorrhea,
chlamydia.
 Bimanual examination:
o establish the direction of the cervix and the size and

35. o exclude the presence of uterine fibroids, adnexal
masses, tenderness.
o Uterosacral ligament nodularity associated with
endometriosis.

36. • Male physical examination :
 urologist usually examines the male partner if the
patient's history of his semen analysis produces an
abnormal finding.
 Attention should be directed to congenital
abnormalities of the genital tract (eg, hypospadias,
cryptorchid, congenital absence of the vas deferens).
 Testicular size, urethral stenosis, and presence of
varicocele are also determined.
 A history of previous inguinal hernia repair can indicate
an accidental ligation of the spermatic artery.

37. Comprehensive evaluation of
infertility :
 Evaluation of infertile couples should be organized
and thorough.
 Diagnostic tests should progress from the simplest
(eg, pelvic ultrasonography) to the more complex and
invasive (eg, laparoscopy).
 Emphasize that a complete infertility evaluation is
performed according to the woman's menstrual cycle
and may take up to 2 menstrual cycles before the
etiology is determined.

38. Evaluation of male partner:
 Male factor is diagnosed in 25-40% of infertile
couples.
 the majority of diagnoses involve testicular pathology
such as varicocele.
 Beyound the history and physical exam , the initial
evaluation of male factor is through semen analysis .
 If abnormal , the semen analysis should be repeated
in 4 weaks or more to confirm normal finding.
 Normal S/A exclude any important male factor ,
whereas abnormal S/A suggests the need for further
evaluation (endocrine , urological, or genetics )

39. A. SEMEN ANALYSIS:
 The male partener should abstain from coitus for 2-5 days
before collecting the sample , and the speciment should
be received in the lab within one hour of collection .
 The basic semen analysis assesses sperm concentration,
motility, morphology, and viability. The World Health
Organization's semen analysis parameters are as
follows :
 Volume - 2-5 mL
 pH level - 7.2-7.8
 Sperm concentration - 20 million or greater
 Motility - 50%, forward progression
 Morphology - Normal sperm (>4%)
 White blood cells - Fewer than 1 million cells/µL

41. Interpretation of semen analysis :
 Spermatogenesis takes approximately 72 days.
 Azoospermia indicates absence of sperm that could
result from congenital absence or bilateral
obstruction of the vas deferens or ejaculatory ducts,
spermatogenesis arrest, Sertoli cell syndrome, or
postvasectomy.
o Important to check their testesterone level , (low level
suggest a production impairment )
o LH /FSH (hypogonadotrophic hypogonadism ) is rare
and can be treated with FSH and HCG injections.
o Also important for screen for Cystic Fibrosis (CF)
mutation as CBAVD is a minor variant of CF .

42.  Oligozoospermia indicates a concentration of fewer
than 20 million sperm/mL and may be associated with
ejaculatory dysfunction such as retrograde
ejaculation, genetic conditions, or hormonal
disturbances.
 Asthenozoospermia indicates sperm motility of less
than 50%. This can be caused by extreme
temperatures and delayed analysis after sperm
collection.
 Teratospermia indicates an increased number of
abnormal sperm morphology at the head, neck, or tail
level.
 Hypospermia indicates a decrease of semen volume
to less than 2 mL per ejaculation.

43. B. Sperm function tests:
 A proliferation of different sperm tests have been
developed to evaluate and predict the sperm fecundability,
including :
1. the acrosome reaction test with fluorescent lectins or
antibodies .
2. computer assessment of the sperm head
3. computer motility assessment
4. hamster penetration test
5. human sperm-zona penetration assay.
 They are subject to variation in interpretation, which
render them more of academic interest than of practical
therapeutic value.

44. Sperm antibodies :
 Sperm agglutination is an indirect indicator of the presence of
sperm antibodies.
 The immunobead test can be performed either directly on the
sperm or indirectly on sperm and blood.
 Surface antibodies against immunoglobulin A (IgA) or
immunoglobulin G (IgG) may be present.
 The antibodies can be specific for the head or for the tail of the
sperm.
 IgA sperm antibodies interfere with the sperm-oocyte
interaction and account for decreased fertilization
 IgG sperm antibodies are more responsible for impaired
sperm motility.
 Sperm antibodies are associated with infection (ie, orchitis),
testicular trauma, and a history of vasectomy.

45. Evaluation of female partner :
 Several congenital or acquired conditions affect
female reproductive function. These conditions alter
the anatomy and/or physiology of reproduction.
 A complete evaluation of the female reproductive
tract must include cervical, uterine, endometrial,
tubal, peritoneal, and ovarian factors.

46. Cervical factors :
1. Postcoital test (PCT)
- Also known as Sims-Hunher test
- the test should be performed as close to ovulation as
possible but not after .
- Involves aspirating cervical mucous with a syringe 6-8 hrs
after coites and checking under a microscope for the
number and motility of the sperm.
-Fewer than 10 motile sperm / high power field is
considered abnormal.
-The PCT is controversial and has a limited use in infertility
work up .

47. II. Speculum examination :
May reveal evidence of Cervicitis or Cervical stenosis .
Complete cervical stenosis is confirmed by the inability
to pass a 1-2 mm probe into the uterine cavity.

48. Uterine factors :
 Many defects can be detected during the pelvic
examination. These include absence of the vagina and
uterus, vaginal septum, and the presence of fibroids.
 Detection of most defects requires ancillary studies
such as HSG, pelvic ultrasonography,
hysterosonogram, and MRI.
 Operative procedures such as laparoscopy and
hysteroscopy are often necessary for confirmation of
the final diagnosis.

49. I. Ultrasonography :
 Pelvic ultrasonography should be part of the routine
gynecologic evaluation because it allows a more
precise evaluation of the position of the uterus within
the pelvis and provides more information about its
size and irregularities.
 .Pelvic sonograms also help in the early detection of
uterine fibroids, endometrial polyps, ovarian cysts,
adnexal masses, and endometriomas.

53.  Ultrasonography can also assist in the diagnosis of
anovulation, polycystic ovaries, and persistent
corpus luteum cysts.

55. I. Hysterosalpingogram :
 The HSG is the most frequently used diagnostic tool
to evaluate the endometrial cavity.
 provides accurate information about the :
o endocervical canal
o diameter and configuration of the internal os
o endometrial cavity
o uterine/tubal junction (cornual ostium)
o diameter, location, and direction of the fallopian tubes
o status of the fimbriae
o spill into the endometrial cavity.

56.  The HSG should be performed during the early
follicular phase. At this time, the endometrium is thin
and the HSG provides better delineation of minor
defects.
 HSG is fluoroscopic study performed by instilling
radioopaque dye into uterine cavity via a catheter .
 The use of water-based contrast media is preferable
to oil-based media to avoid the risks of oil embolism
and granuloma formation.
 Peritonitis is a risk of procedure observed in upto 1-
3% of patients .

58.  Abnormal finding include :
o Congenital malformation of the uterus.
o Submucous leiomyomas
o Intrauterine synechiae (asherman syndrome)
o Intrauterine polyps
o Proximal or distal tubal occlusion .
o Salpingitis isthmica nodusa

59. HSG show Congenital anomalies :

65. III. Saline infusion sonography :
 (SIS) provides a simple and inexpensive means by
which to evaluate the uterine cavity and assess tubal
patency.
 It is well-tolerated by patients and can be done in the
office.
 It eliminates the risks associated with the use of dye
and radiation required by the HSG.

66. Technique of SIS :
 SIS should be performed between days 4 and 10 of
the patient's menstrual cycle.
 the endometrium is at its thinnest, and physiologic
changes during the secretory phase that may
simulate pathologic conditions are not present.
 Before day 4, the presence of blood may either
obscure or simulate a pathologic condition.
 In women with a regular menstrual cycle, performing
SIS before ovulation helps avoid the possibility of
flushing out a fertilized ovum during the procedure.

67.  In patients with an irregular menstrual cycle, a
preprocedure pregnancy test may be performed .
 Prophylactic antibiotics may be administered to patients
who are at increased risk for infection, including those
with an intrauterine device (IUD) and known tubal
occlusion or peritubal adhesions that may cause
increased stasis of saline in the pelvis .
 Pain may be prevented or minimized by administering a
nonsteroidal anti-inflammatory drug (NSAID) 30–60
minutes before the procedure .
 Because patients with adenomyosis may experience
more pain, premedication may be particularly useful in
these patients.

68. Procedure :
 After an initial evaluation of the uterus and adnexa by
vaginal ultrasound .
 a Cusco speculum was inserted and the cervix washed
with an antiseptic solution.
 The anterior lip of the cervix was grasped with a single-
toothed tenaculum and a pediatric Foley catheter (8–
10 f) was introduced into the lower uterine cavity.
 A 20-ml syringe loaded with 0.9% saline solution was
attached to the external end of the catheter after
removal of the speculum and the tenaculum .
 ultrasound probe was reintroduced into the vagina.
 Injecting 20–40 ml of the solution was introduced into
the catheter.

69. Results :
 The patency of Fallopian tubes was determined by
the presence of fluid in the Douglas pouch which
indicates the patency of at least one tube .

70. (a) Preprocedure sagittal
transvaginal US image of the
uterus shows shadowing fibroids
(*)
(b) Transabdominal sagittal US
image of the uterus, obtained
after SIS, shows multiple
intracavitary fibroids (*),

71. :
MRI
IV.
 The use of MRI has increased in recent years,
although it should be limited to those patients in
whom a definitive diagnosis cannot be ascertained
by conventional HSG, ultrasonography, and
hysteroscopy findings.
 MRI is useful for delineating complex pelvic masses
and for assisting in the diagnosis of such conditions
as congenital malformations related to
cryptomenorrhea and absence of the cervix. [

72. Sagittal T2-weighted MR image shows complete absence of the
cervix and uterus with an abnormally truncated vagina ending in
a blind pouch

73. Axial T2-weighted MR image
shows a single uterine horn
(*) and cervix (arrowhead)
Coronal T2-weighted image of
a uterus didelphys, shows two
widely divergent uterine horns
(arrows) Two separate cervices
are present (arrowheads)

74. V.Hysteroscopy :
 is a method of direct visualization of the endometrial
cavity.
 It allows both the diagnosis and treatment of
endometrial pathology.
 treatment of pathologies such as uterine synechiae,
endometrial polyps, submucous myomas, and the
removal of foreign bodies (eg, intrauterine devices).
In combination with specially designed catheters, it
can be used to perform tubal cannulation

76. Hysteroscope show endometrial pathologies .

77. Hysteroscope show uterine congeninital anomalies:

78. Tubal and peritoneal factors :
 The 2 most frequent tests used for diagnosis of tubal
pathology are laparoscopy and hysterosalpingogram.
 Laparoscopy and chromotubation (dye instillation) :
 Laparoscopy is not part of the routine infertility
evaluation. It is used when abnormalities are found on
ultrasonography, HSG, or suspected by symptomology.
 Is the Gold standard for the evaluation of tubal factors ,
and when performed in conjunction with hysteroscopy ,
information on uterine contour can be obtained
simultanously

79. The dx of endometriosis is usually based on laproscopic
finding :

80. Tubal abnormalities such as agglutinated fimbria or
adhesions or beritubal cyst , that would not
necessary be detected by HSG

83. Ovarian factors :
 An ovulatory dysfunction is responsible for
approximately 20-25% of infertility cases (40% of
female factor infertility)
 The problem should be invistigated first by review of
historical factors.
I. Confirmation of ovulation:
-if the patient reports history of regular menses with
molimina (headache, bloating,cramping and emotional
lability ) and mild dysmenorrhea occuring at interval of
28-32 day , the likelihood of the patient having regular
ovulatory cycles is very high.
- Other wise ovulation canbe confirmed with serum

84. - Progesterone level of 3 ng/ml or greater are cosistant
with ovulation.
 Pelvic Ultrasonography :
- Sonographic confirmation of follicle rupture with serial
ultrasonography can also be performed.
 Basal body temperature BBT charts :
- Is temp obtaining in the resting state and should be
taken shortly after awakening in the morning after at
least 6 hrs of sleep and before ambulating.
- Progesterone elevate BBT by 0,8 F during the luteal
phase.
- Temp elevation lasting about 10 days ( Biphasic
pattern).

85.  urinary ovulation predictor kits :
- To detect the LH surge , ovulation occur 24-36hr after
the onset of the LH surge , and 10-12 hr after the peak
of LH surge .
 The only absolute decumentation of release of an
oocyte is pregnancy .

86. II. Ovarian reserve :
 the level of ovarian reserve and the age of the
female partner are the most important prognostic
factors in the fertility workup
 . Ovarian reserve is most commonly evaluated by
checking a cycle day 3 FSH and estradiol level.
 Normal ovarian function is indicated when the FSH
level is less than 10 mIU/mL and the estradiol level is
less than 65 pg/mL.

87.  Clomiphene citrate challenge test (CCCT):
o In cases where the patient is 35 years or older
o A serum FSH and estradiol level is drawn on cycle day
3.
o Clomiphene citrate 100 mg by mouth is administered on
cycle days 5-9 and a serum FSH level is drawn again
on day 10.
o An FSH level greater than 10 is associated with
decreased fertility and lower pregnancy rates.
 A serum AMH assay:
 used to identify patients with decreasing ovarian
reserves and polycystic ovarian insufficiency.
 AMH is produced by granulosa cell.
 In women AMH level decrease with age and are

88. in postmenopausal period .
 Because thyroid disease and hyperprolactinemia can
cause menstrual abnormalities and infertility, a
serum TSH and prolactin should always be checked
and corrected prior to instituting therapy.

89. Conclusions:
 In the assessment of an infertile couple a careful
history , examination, invistigation and when
necessary counselling should include both
parteners.
 The couple should be given information on the
natural conception rate(including the impact of
advanced age).
 Advice on life style issues relating to diet , smoking ,
weight and alcohol consumption so that they can
optimize their pre-conception health.
 Both male and female evaluation are needed to
reach diagnosis .

90.  Male partner:
o History
o Semen analysis
o If semen analysis is abnormal referral to urology ,
endocrine evaluation, and karyotyping in severe
cases.
 Female partner:
o History, confirm ovulation
o Physical examination to assess cervix, uterus, and
adnexa for pathology .
o Cycle day 3 blood work and ultrasound to assess
ovarian reserve
o HSG to evaluate uterine cavity and fallopian tube
o Laproscopy to assess endometriosis when indicated.